| NPI | 1720420896 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101Y00000X Counselor (Licence: NE 2110) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NE 1177) |
| Enumeration Date | 2013-07-18 |
| Last Update Date | 2019-06-12 |